Provider Demographics
NPI:1740637131
Name:KOO, KYUNGJOO
Entity type:Individual
Prefix:MS
First Name:KYUNGJOO
Middle Name:
Last Name:KOO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CECILIA
Other - Middle Name:KYUNGJOO
Other - Last Name:SEO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:440 S VERMONT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1987
Mailing Address - Country:US
Mailing Address - Phone:213-388-4100
Mailing Address - Fax:213-388-4200
Practice Address - Street 1:440 S VERMONT AVE STE 109
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1987
Practice Address - Country:US
Practice Address - Phone:213-388-4100
Practice Address - Fax:213-388-4200
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist